Simulation To Improve Patient Safety: Getting Started

If you have already invested both tangible resources and social capital to develop patient safety infrastructure, simulation can be an additional valuable asset. You may have already assembled committees, built processes, and organized meetings to advance patient safety. Incorporating simulationists into these structures can improve your ability to accomplish your goals and discover information uniquely revealed by simulation. 

At the point of understanding how patient harm occurs, or how successful patient care occurs, simulations can be incorporated in root cause analyses (RCA) or the complementary process of success cause analyses (SCA). SCA investigates the conditions that supported safe, successful care despite unusual (or usual) challenges.⁶ Simulation can take learning one step further by recreating an actual event to better understand factors that contributed to the outcome. Simulation can also serve as a risk mitigation strategy or can be designed to ascertain whether improvements have been sustained.

During a postsimulation debriefing, participants can be encouraged to identify the actions or information other participants provided that contributed to management of the simulated patient. Often, experts contribute to patient care without consciousness of their underlying thought processes, and novices are not sure if their actions were, indeed, correct. Articulating what actions or information were beneficial can improve recognition of contributory actions and reinforce their importance. 

Simulation in situ can be particularly useful; these simulations replicate patient care situations in actual patient care locations, using actual patient care equipment, with the participation of actual patient care team members.^8,9 Simulation in situ can surface differences between “work-as-imagined” and “work-as-done.”⁹ In many cases, differences exist between the idealized conceptual understanding of patient care and the realities of numerous conditions that could be problematic. These include resource limitations, missing equipment, unbalanced workloads, and many other local and systemwide conditions. 

Some latent safety threats or patient safety hazards that are known to local participants, even when not formally reported, become evident during simulations. For example, simulations in situ may reveal that the oxygen supply does not have sufficient pressure to be used for two patients at the same time¹ or that members of a team have differing assumptions about the skills and responsibilities of team members with different scopes of practice. Learning designed to enable future responding teams to provide safe, successful patient care can be elicited during debriefing.^11-13

To encourage participation and collaboration:

• Design introductory simulations that are supportive, engaging, and rewarding. As simulation has been integrated into formal training programs for a variety of healthcare roles,¹⁴ participants may have some familiarity with simulation.
• Focus on improving healthcare systems, rather than improving healthcare providers. Ensure that potential participants are oriented to the objectives of the simulation. 
• Optimize the direct and secondary benefits, such as designing and implementing simulations that address organizational priorities. Another option is to provide formal credit toward credentialing, maintenance of certification, mentoring, or other educational, research, publication, or administrative goals. Simulation can also be used to meet newer Joint Commission accreditation standards, such as the requirement for annual drills to determine system issues as part of ongoing quality improvement efforts in maternal safety.¹⁵ 
• Respect the concurrent clinical care responsibilities of participants by using “no-go” criteria to postpone simulations during periods of increased patient acuity, increased patient census, or limited staffing. Over time, as the benefits of simulation gain appreciation, fewer cancellations may occur.^16,17